Hypothermic Circulatory Arrest in Adult Aortic Arch Surgery: A Review of Hypothermic Circulatory Arrest and its Anesthetic Implications.

Diseases affecting the aortic arch often require surgical intervention. Hypothermic circulatory arrest (HCA) enables a safe approach during open aortic arch surgeries. Additionally, HCA provides neuroprotection by reducing cerebral metabolism and oxygen requirements. However, HCA comes with significant risks (eg, neurologic dysfunction, stroke, and coagulopathy), and the cardiac anesthesiologist must completely understand the surgical techniques, possible complications, and management strategies.

When to operate on the bicuspid valve patient with a modestly dilated ascending aorta.

BACKGROUND: Bicuspid aortic valves (BAV) are frequently associated with root/ascending aorta dilatation, but there is controversy regarding when to operate to prevent dissection of a dilated aorta associated with a well-functioning BAV. METHODS: From 1988 through 2008, 158 patients (mean age: 56 ± 13.5 years) with a dilated ascending aorta (AA) and a well-functioning BAV were referred to our institution. All patients underwent computed tomographic (CT) scanning and digitization to calculate mean AA diameter. Forty-two patients underwent operation a median of 52 days after initial CT scan with a mean AA diameter of 5.6 ± 0.5 cm. One hundred sixteen patients (mean diameter 4.6 ± 0.5 cm) were enrolled in annual or semiannual surveillance. Seventy-one patients, 45 with 2 or more CT scans, are still under surveillance. RESULTS: Average follow-up was 6.5 ± 4.1 years. Overall survival after the first encounter was 93% at 5 years and 85% at 10 years. A total of 87 of 158 patients had a Bentall or Yacoub procedure, with two hospital deaths (2.3%). Mean duration of surveillance in the 116 patients without immediate operation was 4.2 ± 2.9 years (481 patient-years). Average growth rate of the AA in patients with 2 scans or greater was 0.77 mm/year (p < 0.0001 versus normal population) with no significant impact of hypertension, sex, smoking or age. Forty-five of the 116 surveillance patients underwent operation after a mean of 3.4 ± 2.9 years (mean age 55 ± 14.7 years; mean AA diameter 4.9 ± 0.6 cm). Six patients died without surgery, median age 82 (range, 44 to 87) years, but none within one year of the last CT scan. CONCLUSIONS: A consistent approach to patients with a well-functioning BAV and AA dilatation, recommending operation to those with an AA diameter greater than 5 cm and deferring operation in patients under surveillance in the absence of significant enlargement (>0.5 cm/year), resulted in overall survival equivalent to a normal age-matched and sex-matched population. Operation was necessary in approximately 10% of patients under surveillance each year.

Recognition of a cleft mitral valve utilizing real-time three-dimensional transoesophageal echocardiography.

We present a case in which real-time three-dimensional transoesophageal echocardiography was utilized to obtain better understanding of a cleft mitral valve. Additionally, the embryological development of a cleft mitral valve will be reiterated.

Long-term survival after the Bentall procedure in 206 patients with bicuspid aortic valve.

BACKGROUND: The recognition that patients with a bicuspid aortic valve (BAV) are at risk for aorta-related death (rupture or dissection) has favored composite aortic root replacement in BAV patients who undergo aortic valve replacement for valve dysfunction as well as in asymptomatic BAV patients with significant aortic root dilatation. We report the results of Bentall operations in 206 BAV patients during an 18-year interval. METHODS: Two hundred six BAV patients (mean, 53 +/- 14 years, 84% male) underwent composite aortic root replacement between September 1987 and May 2005. One hundred nine patients (53%) presented with aortic regurgitation, 24 patients (12%) presented with aortic stenosis, and 55 patients (26%) presented with combined aortic stenosis and aortic regurgitation. Median preoperative aortic diameter was 5.5 cm (range, 3 to 9 cm). Twenty-two patients (11%) underwent urgent or emergent procedures; 11 had acute type A dissection (5%). Sixty-one percent had a mechanical valve Bentall prosthesis; in 39%, a biologic valve was implanted. Thirty-two percent had concomitant procedures. RESULTS: Overall hospital mortality was 2.9% (n = 6), and stroke rate was 1.9% (n = 4). Risk factors for adverse outcome (death or stroke), which occurred in 4.8% (n = 10), were presence of clot or atheroma (p = 0.02) and age older than 65 years (p = 0.05). During a mean follow-up of 5.9 years (1,200 patient-years; range, 5 to 18 patient-years), no patient required ascending aortic reoperation. Long-term survival was 93% after 5 years and 89% after 10 years. Discharged patients enjoyed survival equivalent to a normal age- and sex-matched population and superior to survival reported for a series of patients with aortic valve replacement alone. CONCLUSIONS: In patients with BAV, the Bentall procedure has an operative mortality no worse than that for aortic valve replacement, with superior long-term survival and a lower rate of aortic reoperation.